Robot-assisted vs. laparoscopic repair of complete upside-down stomach hiatal hernia (the RATHER-study): a prospective comparative single center study

Hiatal Hernia Repair: A Century Between Soresi and da Vinci

A minimally invasive approach is the most common technique for hiatal hernia repair. The robotic platform offers a unique advantage that addresses the limitations of a laparoscopic repair. The steps of a robotic hiatal hernia repair include reduction of hernia contents, dissection of hernia sac, circumferential dissection of esophagus with 2.5 to 3 cm of intraabdominal esophagus, crural closure, and partial or complete fundoplication. The robotic hiatal hernia repair has comparable perioperative outcomes to the laparoscopic approach. This article discusses current controversies, limitations, and new technologies.

Robotics vs Laparoscopy in Foregut Surgery: Systematic Review and Meta-Analysis Analyzing Hiatal Hernia Repair and Heller Myotomy

BACKGROUND

Laparoscopic surgery remains the mainstay of treating foregut pathologies. Several studies have shown improved outcomes with the robotic approach. A systematic review and meta-analysis comparing outcomes of robotic and laparoscopic hiatal hernia repairs (HHR) and Heller myotomy (HM) repairs is needed.

STUDY DESIGN

PubMed, EMBASE, and SCOPUS databases were searched for studies published between January 2010 and November 2022. The risk of bias was assessed using the Cochrane Risk of Bias in Non-Randomized Studies of Interventions tool. Assessed outcomes included intra- and postoperative outcomes. We pooled the dichotomous data using the Mantel-Haenszel random-effects model to report odds ratio (OR) and 95% CIs and continuous data to report mean difference and 95% CIs.

RESULTS

Twenty-two comparative studies enrolling 196,339 patients were included. Thirteen (13,426 robotic and 168,335 laparoscopic patients) studies assessed HHR outcomes, whereas 9 (2,384 robotic and 12,225 laparoscopic patients) assessed HM outcomes. Robotic HHR had a nonsignificantly shorter length of hospital stay (LOS) (mean difference -0.41, 95% CI -0.87 to -0.05), fewer conversions to open (OR 0.22, 95% CI 0.03 to 1.49), and lower morbidity rates (OR 0.76, 95% CI 0.47 to 1.23). Robotic HM led to significantly fewer esophageal perforations (OR 0.36, 95% CI 0.15 to 0.83), reinterventions (OR 0.18, 95% CI 0.07 to 0.47) a nonsignificantly shorter LOS (mean difference -0.31, 95% CI -0.62 to 0.00). Both robotic HM and HHR had significantly longer operative times.

CONCLUSIONS

Laparoscopic and robotic HHR and HM repairs have similar safety profiles and perioperative outcomes. Randomized controlled trials are warranted to compare the 2 methods, given the low-to-moderate quality of included studies.

Robotic versus laparoscopic general surgery in the emergency setting: a systematic review

Robot-assisted general surgery, an advanced technology in minimally invasive procedures, is increasingly employed in elective general surgery, showing benefits over laparoscopy in specific cases. Although laparoscopy remains a standard approach for common acute abdominal conditions, the role of robotic surgery in emergency general surgery remains uncertain. This systematic review aims to compare outcomes in acute general surgery settings for robotic versus laparoscopic surgeries. A PRISMA-compliant systematic search across MEDLINE, EMBASE, Science Citation Index Expanded, and the Cochrane Library was conducted. The literature review focused on articles comparing perioperative outcomes of emergency general surgery managed laparoscopically versus robot-assisted. A descriptive analysis was performed, and outcome measures were recorded. Six articles, involving 1,063 patients, compared outcomes of robotic and laparoscopic procedures. Two articles covered cholecystectomies, while the others addressed ileocaecal resection, subtotal colectomy, hiatal hernia and repair of perforated gastrojejunal ulcers. The level of evidence was low. Laparoscopic bowel resection in patients with inflammatory bowel disease (IBD) had higher complications; no significant differences were found in complications for other operations. Operative time showed no differences for cholecystectomies, but robotic approaches took longer for other procedures. Robotic cases had shorter hospital length of stay, although the associated costs were significantly higher. Perioperative outcomes for emergency robotic surgery in selected general surgery conditions are comparable to laparoscopic surgery. However, recommending robotic surgery in the acute setting necessitates a well-powered large population study for stronger evidence.

Robotic surgery versus Laparoscopic surgery for anti-reflux and hiatal hernia surgery: a short-term outcomes and cost systematic literature review and meta-analysis

PURPOSE

The objective of this study is to compare the operative time, intraoperative complications, length of stay, readmission rates, overall complications, mortality, and cost associated with Robotic Surgery (RS) and Laparascopic Surgery (LS) in anti-reflux and hiatal hernia surgery.

METHODS

A comprehensive literature search was conducted using MEDLINE (via PubMed), Web of Science and Scopus databases. Studies comparing short-term outcomes and cost between RS and LS in patients with anti-reflux and hiatal hernia were included. Data on operative time, complications, length of stay, readmission rates, overall complications, mortality, and cost were extracted. Quality assessment of the included studies was performed using the MINORS scale.

RESULTS

Fourteen retrospective observational studies involving a total of 555,368 participants were included in the meta-analysis. The results showed no statistically significant difference in operative time, intraoperative complications, length of stay, readmission rates, overall complications, and mortality between RS and LS. However, LS was associated with lower costs compared to RS.

CONCLUSION

This systematic review and meta-analysis demonstrates that RS has non-inferior short-term outcomes in anti-reflux and hiatal hernia surgery, compared to LS. LS is more cost-effective, but RS offers potential benefits such as improved visualization and enhanced surgical techniques. Further research, including randomized controlled trials and long-term outcome studies, is needed to validate and refine these findings.

Evidence mapping on how to perform an optimal surgical repair of large hiatal hernias

BACKGROUND

Symptomatic and large hiatal hernia (HH) is a common disorder requiring surgical management. However, there is a lack of systematic, evidence-based recommendations summarizing recent reviews on surgical treatment of symptomatic HH. Therefore, this systematic review aimed to create evidence mapping on the key technical issues of HH repair based on the highest available evidence.

METHODS

A systematic review identified studies on eight key issues of large symptomatic HH repair. The literature was screened for the highest level of evidence (LE from level 1 to 5) according to the Oxford Center for evidence-based medicine's scale. For each topic, only studies of the highest available level of evidence were considered.

RESULTS

Out of the 28.783 studies matching the keyword algorithm, 47 were considered. The following recommendations could be deduced: minimally invasive surgery is the recommended approach (LE 1a); a complete hernia sac dissection should be considered (LE 3b); extensive division of short gastric vessels cannot be recommended; however, limited dissection of the most upper vessels may be helpful for a floppy fundoplication (LE 1a); vagus nerve should be preserved (LE 3b); a dorso-ventral cruroplasty is recommended (LE 1b); routine fundoplication should be considered to prevent postoperative gastroesophageal reflux (LE 2b); posterior partial fundoplication should be favored over other forms of fundoplication (LE 1a); mesh augmentation is indicated in large HH with paraesophageal involvement (LE 1a).

CONCLUSION

The current evidence mapping is a reasonable instrument based on the best evidence available to guide surgeons in determining optimal symptomatic and large HH repair.

Robotic versus laparoscopic surgery for hiatal hernia repair: a systematic literature review and meta-analysis

The number of robotic hiatal hernia repairs (RHHR) is increasing. However, the superiority of this minimally invasive approach remains controversial. The aim of this study was to evaluate the available literature reporting on outcomes of RHHR compared with laparoscopic hiatal hernia repair (LHHR) in adult patients. The design of this systematic review was developed using the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). Web of Science, PubMed, the Cochrane Library, and ClinicalTrials.gov databases were searched. Identified publications were reviewed independently by two authors. High heterogeneity was further explored through sensitivity analysis. The primary endpoint was the development of postoperative complications. Secondary endpoints included operation time, intraoperative complications, 30 day readmission rates and length of stay. The analysis was performed using Stata 17.0 software. A total of 7 studies totaling 10078 patients met the inclusion criteria. Five studies included postoperative complications. The postoperative complications rate was 4.25% (302/7111) in the LHHR group, and 3.49% (38/1088) in the RHHR group. Postoperative complications significantly decreased after RHHR compared with LHHR (OR 0.52; 95% CI 0.36 to 0.75, P = 0.000). Three studies involving 2176 patients reported length of hospital stay. In the three studies, the mean Length of hospital stay was 3.2 days in the RHHR group, and 4.2 days in the LHHR group. Length of hospital stay was decreased by a mean of 0.68 days for RHHR compared with LHHR (WMD, - 0.68 days; 95% CI - 1.32 to - 0.03, P = 0.02). There was no significant difference between the RHHR group and the LHHR group regarding operative time, intraoperative complications, and 30 day readmission (P > 0.05). Our research shows that RHHR may be the better option, as the approach decreases postoperative complications and length of hospital stay.

Robotic-assisted versus laparoscopic paraesophageal hernia repair: a systematic review and meta-analysis

Purpose

The robotic approach offers improved visualization and maneuverability for surgeons. This systematic review aims to compare the outcomes of robotic-assisted and conventional laparoscopic approaches for paraesophageal hernia repair, specifically examining postoperative complications, operative time, hospital stay, and recurrence.

Methods

A systematic review including thorough research through PubMed, Scopus, and Cochrane, was performed and only comparative studies were included. Studies concerning other types of hiatal hernias or children were excluded. A meta-analysis was conducted to compare overall postoperative complications, hospital stay, and operation time.

Results

Ten comparative studies, with 186,259 participants in total, were included in the meta-analysis, but unfortunately, not all of them reported all the outcomes under question. It appeared that there is no statistically significant difference between the conventional laparoscopic and the robotic-assisted approach, regarding the overall postoperative complication rate (odds ratio [OR], 0.56, 95% confidence interval [CI], 0.28-1.11), the mean operation time (t = 1.41; 95% CI, -0.15-0.52; p = 0.22), and the hospital length of stay (t = -1.54; degree of freedom = 8; 95% CI, -0.53-0.11; p = 0.16). Only two studies reported evidence concerning the recurrence rates.

Conclusion

Overall, the robotic-assisted method did not demonstrate superiority over conventional laparoscopic paraesophageal hiatal hernia repair in terms of postoperative complications, operation time, or hospital stay. However, some studies focused on cost and patient characteristics of each group. Further comparative and randomized control studies with longer follow-up periods are needed for more accurate conclusions on short- and long-term outcomes.

Robotic Surgery and Functional Esophageal Disorders: A Systematic Review and Meta-Analysis

The functional disease of the esophago-gastric junction (EGJ) is one of the most common health problems. It often happens that patients suffering from GERD need surgical management. The laparoscopic fundoplication has been considered the gold standard surgical treatment for functional diseases of the EGJ. The aim of our meta-analysis is to investigate functional outcomes after robotic fundoplication compared with conventional laparoscopic fundoplication. A prospective search of online databases was performed by two independent reviewers using the search string "robotic and laparoscopic fundoplication", including all the articles from 1996 to December 2021. The risk of bias within each study was assessed with the Cochrane ROBINS-I and RoB 2.0 tools. Statistical analysis was performed using Review Manager version 5.4. In addition, sixteen studies were included in the final analysis, involving only four RCTs. The primary endpoints were functional outcomes after laparoscopic (LF) and robotic fundoplication (RF). No significant differences between the two groups were found in 30-day readmission rates (p = 0.73), persistence of symptomatology at follow-up (p = 0.60), recurrence (p = 0.36), and reoperation (p = 0.81). The laparoscopic fundoplication represents the gold standard treatment for the functional disease of the EGJ. According to our results, the robotic approach seems to be safe and feasible as well. Further randomized controlled studies are required to better evaluate the advantages of robotic fundoplication.

Similar hospital profits with robotic-assisted paraesophageal hiatal hernia repair, despite higher or supply costs

INTRODUCTION

Robotic-assisted laparoscopic surgery has emerged as an alternative to traditional laparoscopy and may offer some clinical benefits when performing complex hiatal hernia repairs. Many institutions may choose to not invest in robotic surgery because of perceived higher costs, and when they already have proficient laparoscopic surgeons. We hypothesized that the robotic approach would yield lower profits overall due to higher supply costs, while offering comparable outcomes to the traditional laparoscopic approach.

METHODS

Financial and outcomes data from a single quaternary academic center was retrospectively reviewed from a prospectively collected database from July 2020 to May 2021. Laparoscopic hiatal hernia repairs and robotic-assisted repairs were compared for metrics including length of stay, operative time, hospital and supply cost, payments, and profits. Metrics of these two groups were compared using t-test analyses with significance set to p < 0.05.

RESULTS

Seventy-three patients were included with 31 in the robotic group (42.5%) and 42 in the laparoscopic group (57.5%). There were no significant differences in length of stay (robotic mean 2.0 days, laparoscopic 2.55 days, p = 0.09) or operative time (257.6 min vs 256.7 min, p = 0.48) between the two approaches. The robotic approach was associated with higher supply costs ($2,655 vs $2,028, p < 0.001) and patient charges ($63,997 vs $56,276, p < 0.05). Despite higher costs associated with robotics, hospital profits were not different between the two groups ($7,462 vs $7,939, p = 0.42).

CONCLUSION

Despite higher supply costs and charges for robotic-assisted hiatal hernia repair, hospital profits were similar when comparing robotic and laparoscopic approaches. Short-term clinical outcomes were also similar. Programs should do their own analysis to understand their individual cost issues.